To nominate a topic for research in the Program

Please fill in the form below as completely as possible and click on "submit" at the end. If you prefer, you may fill out the Microsoft Word format (.doc) version of the form and e-mail the completed form to effectivehealthcare@ahrq.hhs.gov, or you may print out the completed form and mail it to:

If you have any supporting documents you would like to include with your nomination, you can include them (if mailing), send them as additional attachments (if e-mailing), or you can upload them while submitting the online form. All topic nominations, including those submitted on paper, will appear in the read suggested topics for research section.

Topic Nomination

1. Your Nomination — It is most helpful to the EHC Program to receive the following information about your topic nomination:

A description of a question or questions about a health care test or treatment, including any specific tests or treatments that you would like compared. For example, "For adult patients with a major depressive disorder (MDD), what are the comparative risks and benefits of older versus newer antidepressants?"

Relevant patients, group(s) or subgroups of people. This may include details such as age range, gender, coexisting diagnoses, and reasons for therapy.

The important health-related benefits and harms you are interested in, for example, improvements in symptoms or problems with diagnosis.

Nomination Description

Importance

2. Describe why this topic is important.Why this topic is important

Potential Impact

3. How will an answer to your research question be used or help inform decisions for you or your group?Usefulness of Question for Decision-Making

Impact of EHC Research

4. The EHC Program appreciates the opportunities to collaborate with other organizations who can implement research findings whether through guidelines, decision support, education, or new research. Are there organizations that could use the research finding to change clinical practice? Are you a part of or have you been in contact with any organizations who might implement the research findings? This information is for internal discussion and will not be displayed on the EHC Program Web site. Examples include:

Examples

American Heart Association

American College of Cardiologists

Mental Health America

Association of American Indian Physicians

Depression and Related Affective Disorders Association

Gerontological Society of America

List Organizations

Supporting Document

Upload Document:(Select "Browse..." to upload a file. Only *.DOCX, *.DOC, *.XLSX, *.XLS, or *.PDF files can be uploaded. Limit size is 50MBs.)

Title or Short Description:Comments or Notes About This File

Nominator Information

5. In order to help us to understand the context of your health care question, it would be helpful to know more about you. The answers you give will not influence the progress of your suggestion.

Provide a description of your role or perspective: (e.g. patient/consumer, physician, professional society, administrator):

If you are you making a suggestion on behalf of an organization, please state the name of the organization: (optional)Organization You RepresentPlease tell us how you heard about the Effective Health Care Program: (optional)How you heard about the Effective Health Care programYour name and contact information: (optional)Your personal identification will not be displayed on the Web site, nor will it influence your nomination for Effective Health Care research. It will only be used to contact you for additional information about your nomination if necessary. It is not mandatory that you provide your contact information, but it is often helpful for us to contact the nominator when we need clarification about a research question.Your First Name:Your Last Name:Your Title:Your Organization:Your Email Address:Confirm Your Email Address:May we contact you if we have questions about your nomination?YesNo

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